- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | 26 | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $229.09 / $776.25
| Professional | | $134.90 | $229.09 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $67.61 / $190.55
| Professional | 26 | $35.48 | $67.61 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $302.00
| Professional | TC | $109.65 | $162.18 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $251.19 / $251.19
| Professional | | $58.88 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $70.79
| Facility | 26 | $58.88 | $58.88 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $436.52
| Professional | | $169.82 | $251.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $58.88 / $100.00
| Professional | 26 | $46.77 | $58.88 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $186.21 / $331.13
| Professional | TC | $112.20 | $186.21 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $275.42 / $363.08
| Professional | | $269.15 | $275.42 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $70.79
| Facility | 26 | $58.88 | $58.88 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $275.42 / $426.58
| Professional | | $208.93 | $275.42 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $58.88 / $85.11
| Professional | 26 | $46.77 | $58.88 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $186.21 / $275.42
| Professional | TC | $125.89 | $186.21 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $275.42 / $363.08
| Professional | | $208.93 | $275.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $104.71
| Professional | 26 | $53.70 | $67.61 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $208.93 / $269.15
| Professional | TC | $158.49 | $208.93 | $269.15 |